Douglas, Carl J-74
NEW YORK CITY THE CITY OF NEW YORK it DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
April 30,2020 12:50 AM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-038154
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION -""""""""""-""'""'""""""""""'
CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (Yvvv)
Carl Douglas 69 Male I EVENT 104 29 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Bronx Jack D. Weiler Hospital
CERTIFIER NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT X CREMATION CREMATION APPROVED BY:
OF ME;MLI Kristin Roman
Galina Glazman-Kuczaj DISPOSAL ❑ OTHER M.E.CASE,B20038934
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
(YYYY)
DISPOSITION OF
Pine View Crematory Queensbury, NY DISPOSITION 05 07�2020
THE CERTIFICATE OF DEATH HAVING BEEN FILED AS REQUIRED BY THE HEALTH CODE,AND ALL LAWS AND REGULATIONS
GOVERNING THE PREPARATION AND DISPOSAL OF HUMAN REMAINS HAVING BEEN COMPLIED WITH, PERMISSION IS
HEREBY REQUESTED TO DISPOSE OF THE REMAINS AS IDENTIFIED ABOVE,
FUNERAL NAME OF ESTABLISHMENT ADDRESS CITY AND STATE N.Y.STATE REG.#
ESTABLISHMENT New Leaf Cremation 3930 Long Beach Rd Island Park NY 02058
APPLICANT
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
c�,� /�
Michael Noll cJ s(ootG Sip W.Ek ftni-lNA.he fi .d 14105
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
d' 0 �'• Y NOTICE: This permit is not valid without the seal of the Department
of Health and Mental Hygiene;or if it has been corrected, i
interlined or altered in an manner. •�
y City Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 05 ( 04 )2020 * 00, �. * By Service Evital
MM DD "Y Of NET
Public Health Law Sec. 4145(2b) .i+ 0 1. P f 7 0
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#